Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

I have been thinking a lot about it since the death of a dear friend, Dr. Sam Hughes, professor of anesthesia and perioperative care at the University of California, San Francisco, and an attending physician at San Francisco General Hospital. He died at age 61 on Jan. 20, after a year-long battle with pancreatic cancer.

Whatever the list of requirements to be good doctor might include, Sam embodied most of them: intelligence, charm, curiosity, compassion, and decisiveness, to name a few.

Being a good doctor also demands the willingness to face tough challenges. Sam’s chosen specialty, obstetrical anesthesiology, is one of the “most difficult and anxiety provoking” in medicine, according to Dr. Sue Carlisle, associate dean for San Francisco General and a professor in the University of California, San Francisco School of Medicine.

“You are responsible for two lives at once, both of them young and healthy,” she explained. “Things can go wrong very quickly and you have to make quick, accurate decisions.”

Authority and reassuranceIn another hallmark of a good doctor, Sam was not dogmatic. If a woman wished to have a natural childbirth with no pain medications, he would never try to persuade her otherwise. If she changed her mind halfway through the delivery, he would not gloat or demean her. He believed very strongly that pain medications could be given in such a way as to pose no threat to the mother or the baby.That belief stood as the cornerstone of his professional life. He authored textbooks and research papers, ran conferences and tutored generations of young doctors.

Many of Sam’s former students speak of his ability to engage them with gracious patience as he imparted his vast knowledge in a fascinating way.

With patients, the infectious smile he usually wore on his bearded face could “calm the most terrified person,” one colleague told me. In a matter of seconds, Sam could convey both authority and reassurance. When he would say, “It will be OK. The pain will be gone soon,” he was not lying, and his patients could sense it.

Helping the underservedWhere a doctor chooses to work says much about him. At San Francisco General, signs are printed in dozens of languages. This is the hospital for the underserved — those with too little or no insurance, recent immigrants (with the proper papers and without), and many others on the margins of society. The professional staff are “a self-selected group who works as a team,” as Carlisle likes to say.

Far more than at most hospitals, a nurse's aid would not hesitate to speak up and challenge a surgeon. Everyone feels the same responsibility for the patient. Most of the staff, especially the doctors, could make much more money elsewhere. But few other places offer such satisfaction of caring for so many who could not get it elsewhere. Once he started at General, Sam never desired to work anywhere else.

In the mid-1980s, San Francisco General stood as one of the epicenters of the emerging AIDS epidemic. Many health workers feared they would get infected. The fear was exacerbated by the chief of orthopedic surgery Dr. Lorraine Day, who pushed for laws requiring every patient to be tested for the AIDS virus and insisted on operating in a virtual space suit.

Sam played a big role in diffusing the fear and ending the confrontational atmosphere.

“Dr. Hughes set the highest standard for integrity and professional ethics,” said Dr. Julie Gerberding, now director of the Centers for Disease Control, who worked at San Francisco General at that time. “His commitment to the safe care of people with HIV brought sanity to the operating room in an era when some clinicians were too frightened to take care of infected patients.”

Medicine at its bestIn yet another attribute of a terrific doctor, Sam did not live entirely for his professional life. An openly gay man, he worked for and donated generously to gay rights causes. He loved great food and wine.

At San Francisco General, there is no luxury of just working in a single specialty. I remember many fine meals that were interrupted because Sam had to rush off for an extra shift of providing general anesthesia in the operating room, after a heavy load of cases from traffic accidents or bullet wounds arrived in the trauma center.

Sam also loved his house and garden, the ballet, the symphony and, above all, the opera. He never had intended to work in San Francisco when he arrived in 1980, despite its reputation as gay mecca. He wanted to be in New York near the Metropolitan and City Operas. But after his residency in New York, he traveled to San Francisco for a fellowship with a pioneer of obstetrical anesthesia, Dr. Sol Shnider at University of California, San Francisco. Shnider was a great teacher (and opera lover, coincidentally) who persuaded Sam to stay. Such mentoring is the backbone of medicine at its best.

The thousands of women who experienced painless deliveries and hundreds of young doctors who learned his skills are the legacies of Sam’s 27 years at San Francisco General.